Summary

Continuously verifies, negotiates alternatives and manages care of an assigned patient group to facilitate the achievement of quality and cost effective outcomes and reimbursement for services. Responsible for utilization of systems to obtain certification for payment and utilization review. Participates in quality improvement and evaluation processes related to Utilization Review.

Education

Bachelor of Science in Nursing (BSN) required.

Licensure/Certification

Must be an RN with current license.

Experience

Must have three years recent full-time utilization review, patient accounting or revenue cycle experience or three years of clinical experience in an acute care setting. Preferred experience in Case Management activities and Utilization Review.

Other Qualifications

Demonstrates knowledge of DRG, managed care initiatives, payment methods and statistical analysis. Demonstrates understanding of managed care concepts. Must have good verbal and written communication skills. Must have excellent people skills and the ability to problem solve efficiently and effectively. Must have good organizational skills and flexibility with dealing and multiple tasks at the same time.